Design features of a Mid Level Healthcare Providers

A note for discussion amongst policy makers and implementors

From Dr. T. Sundararaman1, Dr V.R. Muraleedharan

2, dt June 24th, 2018

1. The Objective and a Defnition of MLHP

1.1. A MidLevel Health Care Provider, denotes a category of health care providers who by
virtue of the way they are chosen, trained, deployed and supported, would have the skills
and the motivation to live within communities that require their services and provide
comprehensive primary health care in rural areas and for urban marginalized communities.

1.2. These defnitions can change across nations. The defnition appropriate for use in
India is laid down in India’s National Health Policy 2017 . To quote :

” For expansion of primary care from selective care to comprehensive care, complementary
human resource strategy is the development of a cadre of mid-level care providers. This can
be done through appropriate courses like a B.Sc. in community health and/or through
competency-based bridge courses and short courses. These bridge courses could admit
graduates from different clinical and paramedical backgrounds like AYUSH doctors, B.Sc.
Nurses, Pharmacists, GNMs, etc. and equip them with skills to provide services at the sub-
center and other peripheral levels. Locale based selection, a special curriculum of training
close to the place where they live and work, conditional licensing, enabling legal framework
and a positive practice environment will ensure that this new cadre is preferentially available
where they are needed most, i.e. in the under-served areas. “ (Para 11.4, page 18, NHP 2017)

1.3. This has to be understood as flowing from the key principle of the policy for human
resources for health. To quote:

“The key principle around the policy on human resources for health is that, workforce
performance of the system would be best when we have the most appropriate person, in
terms of both skills and motivation, for the right job in the right place, working within the
right professional and incentive environment.” ( para 11 page 16, NHP 2017)

1.4. It is important that all aspects of this definition and its relationship to the key
principle are respected. There is a concern that when policy goes into implementation some
aspects get amplified and others get lost. It is most welcome that the MLHP is now going
into implementation as part of a comprehensive primary healthcare strategy. At this point
of time it is therefore useful to reflect on the roll out across states and how in the process of

1
Professor, School of Health System Studies, Tata Institute of Social Sciences, Mumbai

2
Professor, Department of Humanities and Social Sciences, Indian Institute of Technology, Madras

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implementation different aspects of the policy articulation get amplified or attenuated
across states, and the implications of these modifications for achieving the policy intent.
There are five key design features where different interpretations are being made.

2. Five Key Design Features:

There are five key design features of the MLHP that are emerging and evolving and where
there is considerable divergences both at conceptual and at the operational level.

a) the Role of the MLHP:

b) the envisaged systems context of the MLHP:

c) the envisaged entry qualifications of the MLHP

d) The plans for bridge course and in-house training.

e) the envisaged legal environment of the MLHP.

3. Role defnition of the MLHP:

3.1. The key questions are whether the MLHP can

a) autonomously diagnose and prescribe treatments and if so what are the

boundaries?;

b) what is the role of the MLHP with respect to chronic illnesses?; and

c) to what extent is preventive care part of the duties or is it only curative care we
are talking off?

3.2. In many states the MLHP is conceptualized as a healthcare provider, providing

diagnosis and treatment for a wide variety of illnesses- going beyond the RCH range. The
focus now is just on increasing footfalls in what is described as a general OPD. The main
function of the HWC becomes to provide ambulatory care nearer to home. Thus, it is more
of providing an alternate healthcare provider where there is no doctor available. The
ultimate focus which should be on population based outcomes, is not drawing necessary
appreciation and attention.

3.3. Our contention is that the above description of the role of MLHP is incomplete.
While it is true that there is a wide variety of acute simple illness that HWCs can and must
treat, and that as a result OPD attendance will significantly increase, the focus of the HWC
must remain population based reductions of disease burdens. Upto now the sub-center was
concerned only with reductions in pregnancy, family planning and child immunization
related interventions and interventions against TB, leprosy, HIV and vector borne diseases-
these together account for less than 20% of morbidities. Such preventive care must extend
to other communicable disease and NCDs too. Here preventive care has to be understood to

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mean both primary and secondary prevention with secondary prevention as the more
measurable activity. False dichotomies between preventive and curative care obfuscate this
simple truth. To explain: the main activities in the TB control programme is case detection
(which requires considerable laboratory and physician support); the making of a treatment
plan (which is a physician role), and then considerable follow up to ensure medication
compliance to ensure cure rates. Of course there is a role for nutrition, occupational health,
tobacco control etc in primary prevention- and one needs to do more in these areas- but
the core of the programme lies in secondary prevention which has a curative character:
early detection and prompt treatment by a primary health care team where a treatment
plan is made by a physician. One can also argue that even in antenatal care this is the logic.
The ANM does ante-natal care where health education plays a big role. But an equally big
role is early detection of complications, its confirmation by a physician and a treatment plan
that is made by the physicians and followed up at the primary care level.

3.4. The HWC extends this logic to 5 more categories of illnesses- NCDs ( viz
hypertension, diabetes, chronic respiratory illness, cancers, epilepsy etc), mental illness,
geriatric and palliative care, oral health, ophthalmic and ENT care. (Even emergency care is
included- but one must specifically discuss what this would mean). In each of these care
areas the HWC has to show population based reductions in disease burden. MLHPs cannot
be expected to make autonomous diagnosis and treatment plans in each of these illness
groups. Physicians ( in this context a medical doctor, sometimes a specialist) would be
required to make a diagnosis, detect complications if any and make treatment plans- which
then the MLHP would ensure compliance with. This follow up will necessarily involve
counselling on risk factors, and access to medication and may involve use of diagnostics as
appropriate. Just like TB control does not depend exclusively on DOTS providers but implies
the existence of a TB unit, the HWC does not exist as a horizontal network which functions
without reference to physicians support.

3.5. With respect to NCDs, the MLHP (a) suspects diagnosis of NCDs, (b) refers NCD patients
for appropriate physician consultation to confirm diagnosis, examine for complications and
make a treatment plan and (c) once the treatment plan is made and communicated, the
MLHP assures follow up. In this context, follow-up would consist of counselling, continued
access to prescribed medication, examination as required to assess progress/control of the
disease and early detection of complications with appropriate referral consultations as
required. It is not expected that MLHPs would make independent and autonomous
confirmed diagnosis of chronic disease and write out treatment plans for the same. For
chronic illness management, the MLHP does not replace the doctor, but extends their
outreach. However, another equally erroneous understanding is that the MLHP has only to
screen and refer – and that there is no subsequent role in NCD management.

3.7. For general outpatient care (understood as management of acute common illnesses),
the MLHP replaces the doctor to the extent any trained para-medical can do so. This implies

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that they would be guided by and bound by the Standard Treatment Guidelines that are
issued for them. The MLHP is meant to work with the team of health workers at the HWC
on a wide range of preventive services.

3.8. For a MLHP to evolve and mature as visualised above, she has to have her motivation
and commitment to function sustained, as it takes time to bring about a culture of practice,
as described above. It will also need the rest of the system, especially the physicians seeing
the referrals to own the MLHP as a part of their team.

4. Systems context of HWC and its implications for MLHP function:

4.1. Human Resources: In many portrayals and reviews of the HWC the emphasis is so
exclusively on the creation and deployment of the MLHP that the HWC is in danger of
slipping into an input based definition and that too a wrong defnition. A HWC is NOT a
health sub-center with a MLHP. The HWC is defined by having a team of at least three,
ideally four health care providers and a team of community health workers (ASHAs). The
HWC should have two, but preferably three multipurpose health workers, and a MLHP. Of
the three MPWs an ideal ration would be two female MPWs and a male MPW. The Center is
broadly committed to paying for the two female MPWs and the MLHP but the male workers
has to be supported from state resources. Potentially many functions of the HWC can start
even before the deployment of a MLHP if it has at least two of these four human resources in
place. The MLHP must have role clarity with respect to the roles of others on the team and
his/her relationship with them. The state leadership should also see the HWC as
operationalized by a team and not by a stand-alone MLHP. Also, the HWC should be seen as
an organic extended part of PHC and CHC.

4.2. One of the biggest challenges of the HWC is in organizing the logistics for availability of
medicines and a few diagnostics at the HWC. The success of the MLHP and indeed of the
HWC depends on how medicines for chronic illness becomes available. When the number of
facilities to be supplied with consumables gets multiplied by a factor of five, there is a huge
logistics challenge. Reports indicate that even TN and Rajasthan, which have the best
logistics in place are at times struggling to ensure uninterrupted drug supplies at the HWC
level. The MLHP must be trained to understand how to deal with logistics issues, even as in
parallel district warehousing and inventory management systems are strengthened to take
on this load.

4.3. An important skill that the MLHP requires is population based analytics build around
simple indicators- essentially indicators like proportion of population where disease is
expected, proportion screened, proportion registered, proportion under regular care etc.
This also requires appropriate digital platforms.

5. Entry qualifications of the MLHP:

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5.1. The entry qualification for a MLHP has to be based on what is most appropriate in
the state to get a person with the right skills and the right motivation. Over-qualified
persons with different expectations of the job, and different career paths in mind will be as
much a problem as a person who is without the skills. Over 70 years we have seen how
difficult it is to get health workers- not only doctors but even technical staff to stay in a PHC.
Sub-centers are in even more remote and isolated locations. The best way to address this
challenge is to first identify which cadre or type of recruit would be committed to live and
work in that region and then build the skills into them, rather than go for a general
recruitment and spend the rest of ones time trying to get them to stay at the sub-center.
Whereever the latter route is followed, even if at time of recruitment they are informed of
the job requirement, soon after joining they bring political pressure to bear to be
transferred to PHCs and CHCs ( for example in Madhya Pradesh).

5.2. Results would be best if there is locality based selection of the MLHP who is sent for
the bridge course. It depends on which is the best qualification available to serve in that
locality. It could be a nurse with GNM or ANM qualifications or a new cadre of rural
medical assistant, or physician assistants. Where support from the PHC is weak due to
poorly-functional Medical officers in the PHC or great distances, a higher qualification
would help since more autnomous decision making is required. But precisely in such
areas, candidates with higher qualifications may be less available. Where PHC support is
good and there is good connectivity, a lower entry qualification would be adequate as
autonomous function required is less. As discussed earlier, for most NCD care clinical
decision making would anyway be limited. DOTS providers for example handle drugs
which have high side effects with very limited training- because their role is limited to
providing access to medication and this includes being aware of side effects.

5.3. Anyway course structures of all existing nursing education and even of other
paramedical and technical staff are all inadequate for HWC role, and it is the bridge
course (and the certification process) that one has to depend on to build the necessary
skills. The point is that if nurses are willing to work in a particular locality they can be
selected, but if there is greater likelihood that ANMs would be more willing to stay and
work in the community then ANMs can be selected too. The extra year of training that a
GNM has over an ANM may not be providing more of the relevant skills since the ANM
course is a multi-purpose worker course which is what we need and the GNM course is
more of nursing in hospital situations which is less required.

6. The Bridge course and in-house training:

6.1. The bridge course has to provide five categories of skills . These can be listed as
follows:

a) skills related to management of common symptoms / common illnesses: This would

include a wider range of communicable diseases ( eg fevers) and injuries than are

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 currently undertaken - though even now they are part of the MPW job description. The
training has to be based on specific graded standard treatmennt guidelines (STGs) issued
for HWCs.

b) the skills needed to undertake their role in NCDs. Here it is a combination of STGs and
care pathways- both of which has to be defined.

c) skills needed to organize the primary prevention activities required of a HWC

d) skills that relate to managing care pathways, referrals, and records for the same as
well as population analytics as appropriate; and

e) skill to managing logistics and team building activities as required.

6.2. Since STGs are dynamic documents, there have to be systems for updation
and refreshers. Clearly training is not a one time activity. Taken together district level
support institutions accordingly should emerge over time.

7. The Legal and Administrative environment of the MLHP.

7.1. A key administrative issue is whether this is a new cadre with a career path, or
whether this is only a task shifting function . If it is the latter the understanding is that
the department draws from other cadre along with pay protection and an incentive.
They can continue in the original cadre and its career path when required. If it is a new
cadre it could be paid above MPW levels but below staff nurse levels initially and rise to
become public health nurses and then public health managers. Decision on this depends
also on the financial consequences for the state and how it is viewed by the state
administration.

7.2. The key legal challenge is about the ability to diagnosis and prescribe. Sooner or later
this would come up. The best way forward would be to start with covering it under
schedule K of the Drugs and Cosmetics Act. In this schedule there is paragraph
introduced for community health workers which can be used to begin with. But
eventually governments will have to move on to make a separate legal provision for it as
an amendment to this Act. States which have made provisions for such practice under
paramedical acts or other similar statutes could also be examined.

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